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Falls and Frailty – Increased muscle strength

Evidence summary (Updated 2022)
A systematic review identified eleven trials investigating the effects of exercise interventions on gait ability in those with frailty. Six studies revealed improvements in gait after the physical training period, whereas five studies demonstrated no improvement. Three of the studies that demonstrated improvements used multi-component exercise programs, two studies used only resistance exercises, and one study used endurance training combined with yoga. The mean improvement in gait ranged from 4% to 50% [1].
A meta-analysis found no effects upon gait speed (n= 3 studies, SMD -0.06 (CI -0.49 to 0.37), moderate heterogeneity) or timed up and go speed (n = 2 studies, SMD 0.57 (CI -0.01 to 1.16), low heterogeneity), but significant differences in muscle strength (n = 4, SMD 0.44 (CI 0.11 to 0.77)), moderate heterogeneity) and balance (n = 3 studies, SMD 0.33 (CI 0.08 to 0.57), low heterogeneity)) were observed. Included studies were generally small and low quality, with short follow-ups and focused on observed physical functioning outcomes [2].
Thirteen studies investigated the effects of exercise interventions on lower-body muscle strength. Nine studies revealed increased muscle strength after the physical training period, whereas four studies did not identify any improvement. Five of the studies that demonstrated enhanced strength used resistance exercise programs, and four studies used multi-component exercise interventions. The mean increase in strength ranged from 6% to 60% [1].
Ten studies investigated the effects of exercise interventions on balance. Eight of the investigations revealed enhanced balance after the physical training period, whereas two studies did not demonstrate any improvement. Seven of the studies with balance improvements used multi-component exercise programs that included balance training, and one study included Tai Chi exercises. The mean improvement in balance ranged from 5% to 80% [1].
There has been greater research into this are in the last 3 years:

A systematic review showed significant improvements following exercise intervention in: handgrip (SMD 0.51, p = 0.001) and lower-limb strength (SMD 0.93, p < 0.001), agility (SMD 0.78, p = 0.003), gait speed (SMD 0.75, p < 0.001), postural stability (SMD 0.68, p = 0.007), functional performance (SMD 0.76, p < 0.001), fat mass (SMD 0.29, p = 0.001), and muscle mass (SMD 0.29, p = 0.002). This was true for both early and late stages of sarcopenia and frailty [3].

A review looking into non-pharmacological interventions for sarcopenia only identified 2 studies; both progressive resistance training providing moderate quality evidence that RT increases muscle mass, strength, and quality; strength and quality improve before mass; low-quality evidence that RT increases lumbar spine BMD (over 12 months) and maintains total hip BMD (over 18 months) [4].

A study to assess the effects of strength training (ST) versus other exercise programs on reducing falls in older adults (≥60 years) found no significant difference in falls incidence (RR = 1.00, CI 0.77–1.30, p = 0.99). But only a small amount of heterogeneous evidence [5].

Home based resistance training had no adverse events; adherence 67%; UHBRT significantly improved lower limb muscle strength (Hedges’ g 0.33; CI 0.11−0.57); muscle power (sit-to-stand test, g = 0.44; CI 0.06−0.84), and balance (postural sway, g = 0.32; CI 0.16−0.49). No improvements in handgrip strength, balance, walking speed, TUG, SPPB, QoL. No reduction in risk or rate of falls [6].

Aerobics combined resistance/strength training (CEX), multi-component training (ME), and dance combined training have positive, significant effects on physical performance (upper and lower body strength, dynamic balance, fall risk, mobility, gait, agility, flexibility) in the elderly. CEX was superior versus aerobic training (AER) alone and resistance/strength training (RES) alone in gait speed, lower limb strength, and trunk fat. CEX was superior to AER in improving sitting and stretching, elbow flexion, knee flexion, shoulder flexion and stretching, strength, body fat, function reach test, 30-s chair standing test and 6-min walking test, and self-evaluation of body function [7]

Resistance training and Whole Body Vibration are comparably effective for improving muscle strength; effects of EMS are unclear (limited data). RT improved some functional performance measures and cross-sectional area of the quadriceps. RT did not affect muscle mass [8]. RT improved muscle mass, strength, power, and functional capacity. RT programmes differed greatly in their design (e.g. frequency, volume, intensity), but were consistently beneficial [9]

No RCT has yet assessed Blood Flow Restriction’s (BFR) effect on falls incidence. All 8 RCTs in this review assessed BFR’s effect on physical function. LL-BFR might increase physical performance and muscle strength [10]

Tai Chi AND Resistance Training in combination: Significant improvement in upper and lower extremity muscle strength, aerobic endurance, balance, and mobility. However, small number of trials, so low certainty [11].

Some studies with small numbers and heterogeneity were inconclusive [12,13]

Exercise improved knee extension strength (SMD 0.14, CI 0.03-0.26, P ≤ 0.01), timed up and go (SMD -1.67, CI -2.43 to -0.91, P < 0.0001), appendicular muscle mass (P = 0.04) and leg muscle mass (P = 0.04). However, only a small number of trials (2-4 studies per outcome in MA) and interventions were heterogeneous. [14].

Quality of evidence
B – large number of studies with large numbers but with heterogeneity in the studies.

Strength of recommendation
1 Strong

Group exercise may produce some benefits to physical functioning, in particular strength and balance, initial conclusions limited by moderate heterogeneity but recent larger systematic reviews reinforce the evidence that physical activity is beneficial in increasing and maintaining strength when continued over time. Exercise prescriptions that start slow and are then gradually titrated to continually deliver a training stimulus in the form of volume, intensity and complexity will be most effective.
Multi-component exercise interventions can currently be recommended for pre-frail and frail older adults to improve muscular strength, gait speed, balance and physical performance, including resistance, aerobic, balance and flexibility tasks, three times per week are most likely to be effective. There is no evidence to suggest exercise is harmful in frail populations.

[1] Cadore EL, Rodríguez-Mañas L, Sinclair A, Izquierdo M. Effects of different exercise interventions on risk of falls, gait ability, and balance in physically frail older adults: a systematic review. Rejuvenation research. 2013 Apr 1;16(2):105-14.
[2] Frost R, Belk C, Jovicic A, Ricciardi F, Kharicha K, Gardner B, Iliffe S, Goodman C, Manthorpe J, Drennan VM, Walters K. Health promotion interventions for community-dwelling older people with mild or pre-frailty: a systematic review and meta-analysis. BMC geriatrics. 2017 Dec;17(1):157.

[3] Talar K, Hernández-Belmonte A, Vetrovsky T, Steffl M, Kałamacka E, Courel-Ibáñez J. Benefits of Resistance Training in Early and Late Stages of Frailty and Sarcopenia: A Systematic Review and Meta-Analysis of Randomized Controlled Studies. J Clin Med. 2021 Apr 12;10(8):1630. doi: 10.3390/jcm10081630. PMID: 33921356; PMCID: PMC8070531.

[4] Atlihan R, Kirk B, Duque G. Non-Pharmacological Interventions in Osteosarcopenia: A Systematic Review. J Nutr Health Aging. 2021;25(1):25-32. doi: 10.1007/s12603-020-1537-7. PMID: 33367459.

[5] Claudino JG, Afonso J, Sarvestan J, Lanza MB, Pennone J, Filho CAC, Serrão JC, Espregueira-Mendes J, Vasconcelos ALV, de Andrade MP, Rocha-Rodrigues S, Andrade R, Ramirez-Campillo R. Strength Training to Prevent Falls in Older Adults: A Systematic Review with Meta-Analysis of Randomized Controlled Trials. J Clin Med. 2021 Jul 20;10(14):3184. doi: 10.3390/jcm10143184. PMID: 34300350; PMCID: PMC8304136.

[6] Mañas A, Gómez-Redondo P, Valenzuela PL, Morales JS, Lucía A, Ara I. Unsupervised home-based resistance training for community-dwelling older adults: A systematic review and meta-analysis of randomized controlled trials. Ageing Res Rev. 2021 Aug;69:101368. doi: 10.1016/j.arr.2021.101368. Epub 2021 May 19. PMID: 34022464.

[7] Bai X, Soh KG, Omar Dev RD, Talib O, Xiao W, Soh KL, Ong SL, Zhao C, Galeru O, Casaru C. Aerobic Exercise Combination Intervention to Improve Physical Performance Among the Elderly: A Systematic Review. Front Physiol. 2022 Jan 4;12:798068. doi: 10.3389/fphys.2021.798068. PMID: 35058805; PMCID: PMC8764279.

[8] Šarabon N, Kozinc Ž, Löfler S, Hofer C. Resistance Exercise, Electrical Muscle Stimulation, and Whole-Body Vibration in Older Adults: Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med. 2020 Sep 8;9(9):2902. doi: 10.3390/jcm9092902. PMID: 32911822; PMCID: PMC7563530.

[9] Lopez P, Pinto RS, Radaelli R, Rech A, Grazioli R, Izquierdo M, Cadore EL. Benefits of resistance training in physically frail elderly: a systematic review. Aging Clin Exp Res. 2018 Aug;30(8):889-899. doi: 10.1007/s40520-017-0863-z. Epub 2017 Nov 29. PMID: 29188577.

[10] Gronlund C, Christoffersen KS, Thomsen K, Masud T, Jepsen DB, Ryg J. Effect of blood-flow restriction exercise on falls and fall related risk factors in older adults 60 years or above: a systematic review. J Musculoskelet Neuronal Interact. 2020 Dec 1;20(4):513-525. PMID: 33265079; PMCID: PMC7716683.

[11] Qi M, Moyle W, Jones C, Weeks B. Tai Chi Combined With Resistance Training for Adults Aged 50 Years and Older: A Systematic Review. J Geriatr Phys Ther. 2020 Jan/Mar;43(1):32-41. doi: 10.1519/JPT.0000000000000218. PMID: 30531200.

[12] de Mello RGB, Dalla Corte RR, Gioscia J, Moriguchi EH. Effects of Physical Exercise Programs on Sarcopenia Management, Dynapenia, and Physical Performance in the Elderly: A Systematic Review of Randomized Clinical Trials. J Aging Res. 2019 Nov 20;2019:1959486. doi: 10.1155/2019/1959486. PMID: 31827927; PMCID: PMC6886343.

[13] Jadczak AD, Makwana N, Luscombe-Marsh N, Visvanathan R, Schultz TJ. Effectiveness of exercise interventions on physical function in community-dwelling frail older people: an umbrella review of systematic reviews. JBI Database System Rev Implement Rep. 2018 Mar;16(3):752-775. doi: 10.11124/JBISRIR-2017-003551. PMID: 29521871.

[14] Vlietstra L, Hendrickx W, Waters DL. Exercise interventions in healthy older adults with sarcopenia: A systematic review and meta-analysis. Australas J Ageing. 2018 Sep;37(3):169-183. doi: 10.1111/ajag.12521. Epub 2018 Apr 11. PMID: 29638028.